92-150
c:rrr or CIIIPBBLL
DBP1'. or PDBLIC WOltD
70 North Pint St.
ca.pbeU, CA 950"
(408) 866-2150 .
Pu1dt No.
Q2-150
RIICRDAaDII!:R'l' PKIIIIrr
(for warJt1nlJ w11:b1D tbe
publ1c riCJht-ot-vay)
Iaaued 4/> ~/ 9 L
Permit exp1raa in 12 _. . AppUcation upi.raa in 6 1108.
APPLXCA'nON - AppUcation ia hereby _de for a Public warJal Pu1dt in accordance with Cupbell
JlUniclpal. COde, Section 11.04. (AppUcation expi.raa in 6 1IDIl1:U it penU.t not: pulled)
A. Workaddre..ortract, 110 E. Latimer
X-Ret. fib
Appl1cat:ion Date 4 - 2 3 - 9 2
utility trench location
~;rlpW'rllk
telephone service to house
B. Nature of work:
C. Attach five (5) copies at a drawinq abavinq the location, extent and d1Mnaian. of the work
The drawinq aIlall allow the relation at the Pft'P08ed work to atatlnq aurtace and underqrouDd
iJDproveaenta. When approved ))y the City Enqineer, _id drawinq bea~a a part at this pum,t.
D. '1'I1e General. Condition. tor all permita are lated on tbe reverse aide. Special Provisiona tor
thia permit are Uated below. Failure to abide ))y theae canditiana and provisiona 11I&1' ruult
in jcm ahut-down and/or torfeiture at Faithtul. Perfonaance Sureti_ and caah deposita. (See
Ganeral Condition. 1 anel 2).
E. An application t.. IlU8t &CCOIIpany thia application. 'l'Ilt. t.. ia nan-nfundable.
NUle at AppUcant PacBell 'l'elephone: 491-2050
Addres.
14~ Is. Montqomery SJ 95110
I. this work beinq elone by the prop.rty owner at thUr own raaidance? --ye. _no
Complete and attach Workers' eompenaation anel COntractor ~omation tons.
'1'I1e Appl1cant/Permittee hereby aqree. ))y affixinq their siqnature to this penait to hold the City at
CAmpbell, it. otticer., aqents anel employ... tree, _te and barIDl_. tro. any claim or cleIII&ncl tor
damaq.. raaultinq trom the work covered by thia pemit.
'1'11. Applicant/Permittee here1)y acknowledq.. that they bave raad and understand both the front and
back of thia p.rmit, anel that they will inform their contractor(a) of the information.
ACCEPTED
Applicant (Permittee, print/aiqn
Data
NOTES: ALL WORK SHAL". CONFORM WITH THE A'1"1'AamD, APPROVED PIANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDI'l'IONS.
THE COHTRAC'l'OR MUS'l' HAVE THIS PERMI'l' AND APPROVED PIANS ON-SID AND MUS'!' JID'1' WI'1'H THE P.W.
INSPEctOR ON 'l'BE SITE AT LEAST TWO DAYS BEFORE S'l'ARTING WORK. APPLICAN'l' MUST COH'l'AC'1' '1'HE INSPEC'1'OR
TO ARRANGE nELD MEE'l'ING.
NOTICE MUST BB GIVEN TO PUBLIC W01UtS AT LEAST 24 HOURS BEFORE RDTARTDfG AllY WORK.
SPECIAL PROVTSIONS
V-;.
_2.
Street shall not be open cut for unelerqround installation.. llinilDwa cuta may be allowed
tor connection. or exploration holea. Such cuta must be sDeciticallv aDDraYeel bv the
InBne~or nrior to eu~~1na.
pav_ant _y be cut for underqround install.tion. and _t be raatoreel 1D accordance with
the Utility Trench Reatoration Stanard Dravinq.
Work to be .takecl ))y a Ucen.ecl Land Sunreyor or C1vil EDqineer and two (2) copi.. at the
cut aIle.t. .ant to the Public Work Departmant befon -.tartinq work.
The hours of work are lllDitecl to outaiele the hours at 7-9 .... and 3-6 p.m. tor any work
attectinq a tr.ftic lane.
_3.
_4.
_!S.
S'l'AHDARD
AMOtm'l'
$ \C~ c.r::.
.
$
$
$ l~. c.c::> q
4--'"2.~ -9'2-
RECEIPT NO.
PERMIT APPLICU'ION PEE
PLAH CBEa DBI'OSrr
SURETY POll l"ArrBPUL PERPORIWla: